159943 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: T361333 Page 1 of 1
ONE CIVIC SQUARE JANET KADEL CHECK AMOUNT: $63.71
CARMEL, INDIANA 46032 11616 EDEN GLEN DRIVE
CARMEL IN 46033 CHECK NUMBER: 159943
CHECK DATE: 5/28/2008
DEPARTMENT ACCOUNT PO NUMBER INV OICE NUMB AMOUNT DESCRIPTION
,02 5023990 63.71 REFUND
I
Date: 05/12/2008
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
Bill To: JANET E KADEL ICD -9: 8748 E8881
11616 EDEN GLEN DR
CARMEL, IN 46033
From: 11616 EDEN GLEN DR
To: CLARIAN NORTH
1 MEDICARE PART B
Patient: JANET E KADEL 296147739A
11616 EDEN GLEN DR Insurance
CARMEL, IN 46033 2 MERITAIN HEALTH
760536949451
Patient No: 200800199
YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$318.75 $318.75 $0.00
CPT
Date Description Charges Credits
01/15/2008 BASIC LIFE SUPP EMERGENCE A0429 $300.00
01/15/2008 MILEAGE A0425 $18.75
03/31/2008 MEDICARE PAYMENT $254.83
03/31/2008 ASSIGNMENT MEDICARE $0.21
04/25/2008 PAYMENT $63.71
05/07/2008 COMMERCIAL INSURANCE. PAYMENT $63.71
05/12/2008 REFUND -63.71
I
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
Date: 05/12/2008
1
CARMEL FIRE DEPARTMENT
EMERGENCY MED SVCS
2 CIVIC SQUARE
CARMEL, IN 46032-
(317)571 -2605 Federal 1D# 356000972
a U
Bill To: JANET E KADEL ICD -9: 8748 E8881
11616 EDEN GLEN DR
CARMEL, IN 46033
From: 11616 EDEN GLEN DR
To: CLARIAN NORTH
MEDICARE PART B
Patient: JANET E KADEL 296147739A
11616 EDEN GLEN DR Insurance
CARMEL, IN 46033 2 MERITAIN HEALTH
Patient No: 200800199 760536949451
YOUR SECONDARY INSURANCE HAS DENIED PAYMENT ON THIS CLAIM. THE AMOUNT SHOWN IS YOUR RESPONSIBILITY AND
IS DUE AND PAYABLE NOW. THANK YOU.
Total Amount Total Paid Balance
$318.75 $382.46 -63.71
CPT
Date Description Charges Credits
01/15/2008 BASIC LIFE SUPP- EMERGENCY A0429 $300.00
01/15/2008 MILEAGE A0425 $18.75
03/31/2008 MEDICARE PAYMENT $254.83
03/31/2008 ASSIGNMENT MEDICARE $0.21
04/25/2008 PAYMENT $63.71
05/07/2008 COMMERCIAL INSURANCE PAYMENT $63.71
APPROVED BY THE STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL, 1999
if
garret S Kadel 4 -81 8252
Patricia 1 4 wood
11616 8dett Glen Ddue Date z 56-1506,422. 1425
6anwel, J V 46033
Plt 317 -846 -1603
Pay to the o der of
/l Dollars
ongi ®sir
huntington.com
For
1 04221S060 2443L,207C3E, 252
MERITAIN HEALTH Administered b} MERITAIN HEALTH
300 Corporate ftwN
Amherst. NY 14226-3921
Claim No.: 040('7820S55000200 -MM
G roup Namc: 'I 16V k,'E'LSFY I IA)'L`S
Return Service Requested Group Ident: 8('7S
Dept Cooc:
Employee: JANFTKADE'l,
3-DIGIT 460 Patient: jANj-j'KA1X1
11020 0.3840 AT 11-33LI
Patient Acct: 200900109
Provider CARMF]L, FWI; D1T/\RTN/11:
CARMEL FIRE DEPARTMENT AMBULAN 7; 1 Member ID: 7605)6949451
2 CIVIC SQ 29/2009
CARMEL, IN 46032-2584 P r e Jared Ott: 04/
Patient Responsibility
Amount Not Covered:
Co-Pav Amount: .00
Deductible: .00
Co-Insurance: .00
Patient's Total Responsibility: .00
EXPLANATION OF BENEFITS-- This is NOT a Bill Other Insurance Payment: 2 i 1. 83)
f
I' s-cl nl
oent Dates ser Proc. Billed I.Surchar2c No( NeaS40111 I'M C
I overed 1 I)cductihic C o Pa. Paid
I e I)iscoun Amount �mouikt At
codt. A,111401110 Amount Cm red Code Amomit
lli_ol 9( I
lfl/�51;20 it\0419 loo oo PC .00 .00 0( )0'!,, 1 299791
1 1 00 I
101115-0 5!20 8 7 !A0425 1 IN.75 I 00 1 00 ()O'�J 18 7'
.001 .00
31 I .00i 0.211 .00 318.S41 00 mo 1
3 1S 4
Other Insurance Crefflisand/or Surcharge I 254.83
Total PaYment,
Surcharge Paid W)
Payment ro: Check No. Amount
C.A_RNIEL FIRI!, I FNTAN lit i 119829 ""1:63.71"
service code Reason Code
iJ17 C6 ANI0I_T.N`T DISA1.1,0WED BYNIEDICARE
messaues
HENE FTTS C 00 RI) IN ATED \V I'I'l I X;I F I) IC AR E. N I El) ICA It F ASS] ON N I EN'l ACC Ell' 1).
For eh�ibility. henefin and claim status call 716-319-5800 or 1-800-397-1122. FOR I)IRECTCl.AJXI SUBJUSSIONS. PLEASk Si HNIFF I.:11,1=C'1'1t()NII("A1,1,,)
\71A VIEB1\41) (11),i 64157) OR NICKE'SSON 11 1 761)-
cBjv BD
U. F.bR'StCLiAltY:PORPb!§ti-z,THi OF THIS DOCUMENT CONTAINS 'ff A BLUEBACKGROUND AND:'MICROPRINTING'IN.-THE
'C 4`98 9
K`,NO:� 1
N1 EIZ V -h�.AiJ
71 C' hL1 c, I CYIE
213
VOW AFXER 180 D
A YS
04
Clann'Numbei OC782( _'_5'50b020()-' mm
DATE-;, �:A4/29/0&
go ASSUE,
Putt i�a
Acct2008001
v _7 7 i
-PAY SIXTY TH REE D OL LA RS AND 7 1 A 00 An
1
6 3 7 1 JI
TO THE CARMEL FIRE DEPARTMENT AMBULANCE
ORDER OF 2 CIVIC SQ
'co
CARMEL IN 46032-7543
.11' N'lor"all Chase
Syracuse, NY 13206
Authorized Signature
,-..,..IDO:NOT.(CASH,,IFW
ATERM A FW IS NOTaPRESENI9Or\';THE:REVERSE SIDE OFTHIS. DOCUMENT-- ;HOLD;AT=ANANGLIE-TO �'�7!
Il DO L '898 2911" 1:0 2 '23O91?9I:EO 'a 8808 L13115
VOUCHER NO. WARRANT NO.
ALLOWED 20
xQ IN SUM OF
�Ctln� q-1, L Al z16 D 3
Zo 27
ON ACCOUNT OF APPROPRIATION FOR
in b�lct'e
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
20�
7
lia u 1
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
4
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
IC�-Y) Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
u� e 60-1 1p3 7/
Total 1 0
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer